Factors associated with elder abuse and neglect in rural Uganda: A cross-sectional study of community older adults attending an outpatient clinic

Background Elderlies are vulnerable to abuse, and evidence suggests that one in three elderlies experience abuse. Abuse can impact the well-being of older persons, decreasing their quality of life, leading to mental health challenges, and increasing morbidity and mortality rates. Evidence on older person/elder abuse and neglect is vital to facilitate initiatives, but there are fewer studies on elder abuse and neglect in Africa, particularly in Uganda. Thus, this study aimed to determine the prevalence of different types of abuse and neglect, and their associated factors among older persons (aged 60 years and above) attending an outpatient clinic. Methods In this cross-sectional study, information on sociodemographic characteristics, functional impairment using the Barthel Index, and elder abuse severity using the Hwalek-Sengstock Elder Abuse Screening Test were collected. In addition, types of abuse were assessed using questions adapted from the US National Research Council on elder mistreatment monograph. Linear and logistic regression analyses were used to determine the factors associated with elder abuse severity and the different types of abuse, respectively. Results Overall, the prevalence of elder abuse was 89.0%. Neglect was the most common type of elder abuse (86%), followed by emotional abuse (49%), financial abuse (46.8%), physical mistreatment (25%), and sexual abuse (6.8%). About 30.4% of the abused elders experienced at least two forms of abuse. Factors associated with elder abuse severity were having a secondary level of education and physical impairment. Moderate to severe functional dependence was associated with almost all forms of abuse. Individuals who reported the presence of a perpetrator were likely to experience neglect, emotional, and physical mistreatment. However, those who reported their perpetrators to the police had a higher likelihood of experiencing emotional abuse but were less likely to experience financial abuse. Emotional abuse was also associated with age above 80 years and attaining education (primary and secondary). Physical impairment and chronic medical conditions reduced the likelihood of experiencing neglect and financial abuse, and physical abuse, respectively. Conclusions Uganda has a high prevalence of elder abuse and neglect. There is a need to design interventions for older adults at risk to prevent elder abuse from escalating further, where the present findings can be worthy of help.

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Consult the submission guidelines for detailed instructions. Make sure that all The study received ethics approval from the research ethics committee of Mbarara University of Science and Technology (approval number: . The director of MRRH granted permission to collect data from participants. All participants provided voluntary written informed consent at study enrollment.
information entered here is included in the Methods section of the manuscript.  were used to determine the factors associated with elderly abuse severity and the different 35 types of abuse, respectively. Results: Overall, the prevalence of elder abuse was 89.0%.

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Neglect was the most common type of elderly abuse (86%), followed by emotional (49%), 37 financial (46.8%), physical mistreatment (25%), and sexual (6.8%). About 30.4% of the 38 abused elderlies experienced at least two forms of abuse. The factors associated with an 39 increase in elderly abuse severity were having a secondary level of education and physical 40 impairment. Moderate to severe functional dependence was associated with almost all forms 41 of abuse. Individuals who reported the presence of a perpetrator were likely to experience 42 neglect, emotional, and physical mistreatment. However, those who reported their 43 perpetrators to the police had a higher likelihood of experiencing emotional abuse but were 44 less likely to experience financial abuse. Emotional abuse was also associated with age above 45 80 years and attaining education (primary and secondary). Physical impairment and chronic 46 medical conditions reduced the likelihood of experiencing neglect and financial abuse, and 47 1.0. Introduction 56 Due to several factors, such as higher life expectancy, lower fertility rates, improved 57 healthcare systems, and longevity, the aged population is increasing globally [1]. About 1 58 billion people aged 60 years or above will increase to 1.4 billion and 2.1 billion by 2030 and 59 2050, respectively [2]. In low-and middle-income countries (LMICs), the expected population 60 growth rates remain higher than in high-income countries [3], and 80% of the global older 61 adults will be in LMICs by the year 2050 [2]. However, the increasing older adult population 62 faces physical and mental health challenges, including elder abuse [4]. For instance, in 63 Uganda, the elderly face multiple challenges, including poverty, poor health, unemployment, 64 chronic ill-health, HIV/AIDS, lack of social security systems, low land productivity, political 65 instability, low agricultural returns, and functional inability [5][6][7][8]. These challenges impact 66 their quality of life and make them susceptible to neglect and abuse by their peers and family 67 members [5,9]. institutional abuse [5,9]. Evidence from a systematic review of past-year abuse showed abuse 72 among 15.7% of older persons [11]; emotional abuse was dominant at 11.6%, followed by 73 financial (6.8%), then neglect at 4.2%, and sexual abuse least experienced at 0.9% [11]. In 74 Europe, prevalence varies from 2.2% (Ireland) and 61.1% (Croatia), whereas, in Asia, the 75 highest prevalence was reported in China (36.2%), and the lowest was in India at 14.0%, as 76 per a systematic review [12]. In South Africa, men's and women's prevalences were 64.3% 77 and 60.3%, respectively. Physical abuse was more common among men, while emotional,  Elder abuse is also associated with various adverse health outcomes, including physical and 94 psychological effects that have long-term effects such as depression, anxiety, and post-95 traumatic disorder [17]. It also can pose significant complications, such as premature death.

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For example, community-dwelling middle-aged and older women who reported prior 97 physical, verbal, or both types of abuse had significantly higher adjusted mortality risk than 98 Elderly abuse in Uganda 4 women who did not report abuse [18]. In addition, reported and corroborated elder 99 mistreatment is associated with shorter survival in both women and men [19]. Abused elders 100 also face complications such as post-traumatic stress disorder, poorly controlled chronic 101 diseases such as hypertension, diabetes, heart disease, decreased quality of life, and loss of 102 trust or quality of relationships [20]. Furthermore, elder abuse poses significant complications 103 to society, like the cost of care for victims, the use of community legal and law enforcement 104 resources, and the burden on nursing facilities [20].

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Despite the dangers of elder abuse, information on the prevalence, types, and factors 106 associated with elder abuse in Africa is sparse. Therefore, the present study aimed to 107 determine the prevalence of elderly abuse, the various types of abuse, and their associated 108 factors in a Ugandan elderly sample attending tertiary hospital outpatient clinics. This study was a cross-sectional descriptive study done in February 2021 among older adults 112 aged 60 years and above attending a referral hospital outpatient clinic in Uganda that attends 113 to approximately 600 older adults every month [6,21]. After receiving care for various 114 ailments, elders were recruited from the outpatient departments by convenience sampling.

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Based on the Mini-Mental Status Examination, we excluded elders with severe 116 neurocognitive impairment (a score of 17 and below). We thus recruited 363 participants.

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The research assistants identified participants who met the inclusion criteria and fast-tracked 119 them to receive medical care after completing the interview. Then, they collected data and 120 interviewed each participant for a minimum of 40 minutes using translated questionnaires. property. In addition, we asked about chronic medical illnesses such as cancer, HIV, diabetes, 129 hypertension, etc., and physical impairment such as blindness, lame, and crippled. The Hwalek-Sengstock Elder Abuse Screening Test (HS-EAST) was used to screen for elderly 132 abuse severity [22]. The scale consists of 15 items and three conceptual categories. These three 133 conceptual categories include "overt violation of personal rights and direct abuse" (items 4, 134 9, 10, 11, 15) and "characteristics of elder that make him or her vulnerable to abuse" (items 1, 3 and 6) and characteristics of potentially abusive situations (items 2, 5, 7, 8, 12, 13 and 14) 136 [23]. It is scored by summing responses from each item (Yes/No), where 'Yes' -scored one 137 and 'No' -scored 0. Possible scores range from 0 to 15, where a higher score represents higher 138 exposure to elderly abuse. Based on previous studies, the HS-EAST had a cutoff of 3 and 139 above with a sensitivity and specificity of 82.8% and 84.5%, respectively, for elderly abuse; 140 and a reported Cronbach alpha of 0.741 [24]. In this study, the Cronbach alpha was 0.78.

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In addition to elderly abuse, different types of abuse experienced in the past six months (such 142 as physical, emotional, and financial abuse) were assessed using questions adapted from the 143 National Research Council on elder mistreatment monograph, Supplementary File 1 [15]. 144 Lastly, the older adults who preferred to report also gave information about the perpetrators. The level of functionality was tested using the Barthel Index (BI). The BI is composed of 10 147 items with varying weights [25]. The tool has two items assessing personal care (wash face, 148 comb hair, shave, and clean teeth) and bathing evaluated with a 2-score scale (0 and 5 points); 149 6 items regarding feeding, getting onto and off the toilet, ascending and descending stairs, 150 dressing, controlling bowels, and controlling bladder are evaluated with a 3-score t scale (0, 151 5, and 10 points); and two items regarding moving from wheelchair to bed and returning, and 152 walking on a level surface are evaluated with a 4-score scale (0, 5, 10, and 15 points). The BI 153 is a cumulative score calculated by summing each item's score. The BI scores are multiples of Cronbach alpha for BI is 0.81 [25]. For this study, the Cronbach alpha was 0.88.

Data analysis
Data was initially entered into an excel sheet and then exported to STATA 16.0 for the final 176 analysis. Chi-square tests were performed to determine significant differences between 177 individuals who experienced various forms of abuse and those who did not. For elder abuse 178 severity based on the HS-EAST, we ran a t-test and ANOVA for the elderly abuse severity.

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Linear regression analysis determined the factors associated with elder abuse severity. A back 180 stepwise multivariable linear regression was built after testing for collinearity to adjust for a 181 cofounder. In addition, logistic regression was used to determine the factors associated with 182 the different types of elderly abuse (neglect, physical, sexual, emotional, and financial abuse).

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The significant level was set at less than 5% for a 95% confidence interval.

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Participants with physical impairment had higher elderly abuse severity mean scores than 198 those without physical impairments (6.56% vs 5.90%, t=-3.71, p<0.001). Also, elders' who 199 stayed in government-owned housing had higher elderly abuse severity mean scores (F=4.15, 200 p=0.016), and those whose highest level of education was post-secondary had the lowest 201 elderly abuse severity score as per the education level (F=5.03, p=0.002) ( Table 2).

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At bivariate analysis, the factors that increased elderly abuse severity were: being divorced or 204 separated, previously informally employed and currently still active, having a secondary level 205 of education, staying in a government-owned house, and having a physical impairment.

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These factors were tested for collinearity and had VIFs below 3; the mean VIF was 1.14. They  The prevalences of the different types of abuse were 86.3%, 49.0%, 46.8%, 22.2%, and 6.51, 214 for neglect, emotional, financial, physical, and sexual abuse, respectively. About 30.4% of the 215 participants experienced any two types of abuse (Figure 1), and a majority (66.6%, n = 243) 216 experienced both physical mistreatment and neglect (

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The was no gender difference between the level of sexual abuse experienced (Supplementary 316 file 2). No factor was associated with sexual abuse. (Supplementary file 3)

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In this survey of older adults aged 60 years and above attending an outpatient department of 319 a tertiary hospital in Southwestern Uganda, the prevalence of elderly abuse (cutoff of 3 out of 320 15 at the HS-EAST) was high (89.0%). The factors associated with an increase in the elderly 321 abuse severity were having a secondary level of education and having a physical impairment.

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However, the prevalence of the various types of elder abuse was highest with neglect (86.0%) 323 and lowest with sexual abuse (6.8%), and about 30.4% of the abused experienced at least two 324 forms of abuse, especially physical mistreatment and neglect. Moderate to severe functional 325 dependence was associated with all forms of abuse apart from sexual abuse. Individuals who 326 reported a perpetrator were likely to experience neglect, emotional, and physical 327 mistreatment. However, those who reported their perpetrators to the police had a higher 328 likelihood of experiencing emotional abuse but were less likely to experience financial abuse.

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Emotional abuse was also associated with age above 80 years and attaining education 330 (primary and secondary). Physical impairment and chronic medical conditions reduced the 331 likelihood of experiencing neglect and financial abuse, and physical abuse, respectively.

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The prevalence of elderly abuse ( 89.0%) was much higher than that estimated from India as injuries, illness, and mental health challenges [31]. In addition, the current study was in a 338 country with limited laws and follow-up on elderly abuse, on top of a culture system diluted 339 to the extent of the young or their children disrespecting the elderly [5].

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In this study, having a secondary level of education (more than eight years of study in 341 Uganda) increased the elderly abuse severity. A finding contrary to other study findings, 342 which report that a history of education for more than eight years reduced elderly abuse 343 severity [32]. Older adults with higher education levels can claim their rights, easily report 344 abuse to responsible bodies, and even get more social respect [32]. However, recently older 345 adults in Uganda have been disrespected by the young due to rapid cultural change [5], which 346 puts many older adults at risk of abuse. In addition, the country is a low-income country with 347 challenges such as unemployment, poverty, and a high fertility rate -many of the younger 348 individuals financially exploit the weak and vulnerable elderly, especially the educated who 349 might have been financially stable and have accumulated some assets over time so that they 350 grab or sell their assets and earn some money [5]. No wonder these older adults with a higher 351 level of education are at a higher likelihood of being financially abused in our study.

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Also, older adults with physical impairment had more severe elderly abuse in this study, a 353 finding similar to that reported in the previous studies [13,28]. This finding is not surprising 354 as people with disabilities depend on others, especially in fulfilling their daily activities [33].

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In addition, older adults with physical impairment may not defend themselves or report their 356 perpetrators to the police due to their inability to fight for themselves and fear of being  leading them to abuse financially stable or dependent older adults. Financially stable or 364 dependent older adults become a primary target by some poor youth due to their 365 vulnerabilities due to old age. Financial abuse in this study was associated with increasing age 366 above 80 years because individuals above 80 years are more vulnerable to abuse. After all, 367 they are at higher risk of neurocognitive disorders and functional dependence, which makes 368 them unable to manage their finances or forget to request financial assistance [6]. They may 369 also be more likely to make poor financial decisions and fall victim to fraudulent deals [37]. 370 An increase in functional dependency with age is a major factor that increases the likelihood 371 of almost all types of abuse except sexual abuse due to increased vulnerability and need for 372 help in most of their daily activities. An elderly with a high level of functional dependence 373 causes significant care burden stress, leading to an increased likelihood of abuse [38].

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The likelihood of being financially abused was reduced when the older adult reported the 375 known victim to the police. Reporting the perpetrators to the police, a method suggested by 376 the CDC to reduce abuse, was effective in this study [4]. A perpetrator reported to the police may be punished for their acts, for instance, taken away from the community or the victims' 378 premises, thus, reducing further abuse. In addition, reporting a perpetrator to the police will 379 make the community aware of the perpetrating persons, which will protect the potential 380 victims. This community support may provide emotional and social support, thus reducing 381 the likelihood of experiencing emotional abuse and other forms of elderly abuse. In Uganda, 382 the community considers abuse of an older adult taboo [5]. Disrespecting or abusing an older 383 adult with a disability is considered a worse offence by the community. Due to this respect 384 and possible fear of the community reaction, many perpetrators do not abuse older adults 385 with physical disabilities. The respect they give individuals with a disability may be 386 responsible for them being less likely to experience financial abuse and neglect since every 387 community member expects one to take good care of them.

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Nearly half of all older adults in this study experienced emotional abuse, comparable to 411 findings in South Africa, Nigeria,and Egypt [13,35,44]. These findings could be because 412 there are ways of addressing older adults in traditional African society, and a deviation from 413 this norm is easily noticeable and considered disrespectful [34]. However, the prevalence of 414 emotional abuse was much higher than that reported by Cadmus and Owoaje (2012) in 415 Nigeria among women without psychiatric illnesses [34]. Despite psychiatric illnesses such as

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As reported by other researchers in Africa [26,35], neglect was the most dominant type of 422 abuse. This high prevalence could be attributed to the loss of caregivers due to the HIV 423 scourge in Africa or the migration of family members to urban areas compounded by the loss 424 of extended family ties leaving the elders to fend for themselves and hence feel neglected [45].

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Poverty is another factor that could explain high-rate neglect, as caregivers cannot take care 426 of their own families, let alone older adults [46]. In addition, this study recruited older adults 427 seeking care in hospitals with a high probability of having chronic illnesses, which put them care of them since not caring for the physically impaired is not culturally accepted [5]. Sexual abuse was the least prevalent type, similar to other studies [11,13,34,42,50,51]. In 436 the current study, there was no factor associated with sexual abuse. However, studies in South

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First, the study was cross-sectional in design, so causality between elder abuse and its 445 predictors can not be determined. Second, the study was hospital-based; therefore, elders at 446 higher risk of abuse were sampled, leading to overestimating the prevalence rates. Lastly, the 447 tool used to determine abuse was not adapted in Uganda; therefore, it could have been 448 estimated as higher than the actual prevalence.